Provider Demographics
NPI:1215562954
Name:ANTWINE, ANGELLE VERNE'
Entity Type:Individual
Prefix:
First Name:ANGELLE
Middle Name:VERNE'
Last Name:ANTWINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4951 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6156
Mailing Address - Country:US
Mailing Address - Phone:318-340-1535
Mailing Address - Fax:
Practice Address - Street 1:4951 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-6156
Practice Address - Country:US
Practice Address - Phone:318-340-1535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1215562954171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator